NCLEX-PN clinical judgment practice questions, set 34
NCLEX-PN · clinical judgment
NCLEX-PN clinical judgment practice questionsset 34
You notice cues, form a hypothesis, act, and evaluate — the same loop Next Generation items reward. Five of the 15 questions include the correct answer and rationale. The other ten keep answers in the study hub. Continue with the NCLEX-PN exam guide or more NCLEX-PN practice questions.
Five clinical judgment questions with answers
Cover the key. Write the first action. Then open the rationale and name why the other choices fail.
Question 1
All of the following factors, when identified in the history of a family, are correlated with poverty except:
A. high infant mortality rate
B. frequent use of Emergency Departments
C. consultation with folk healers
D. low incidence of dental problems
Show answer and rationale
Correct answer: D — low incidence of dental problems
The correct answer is 'low incidence of dental problems.' Dental problems are prevalent in families living in poverty due to the lack of preventive care and access to dental services. High infant mortality rate is closely correlated with poverty as it reflects various social determinants of health. Families in poverty may resort to frequent use of Emergency Departments due to limited access to primary care. Consulting with folk healers is also common among families in poverty as they might seek alternative and more accessible healthcare options. However, a low incidence of dental problems is less likely in families experiencing poverty.
Question 2
When a client wishes to improve her appearance by removing excess skin from her face and neck, the nurse should provide teaching regarding which of the following procedures?
A. dermabrasion
B. rhinoplasty
C. blepharoplasty
D. rhytidectomy
Show answer and rationale
Correct answer: D — rhytidectomy
The correct answer is 'rhytidectomy.' Rhytidectomy, commonly known as a face-lift, is the procedure for removing excess skin from the face and neck. Dermabrasion involves spraying a chemical to freeze the skin lightly, followed by abrasion with sandpaper or a revolving wire brush, used for removing scars, severe acne, and tattoo pigment. Rhinoplasty is for improving the nose's appearance by reshaping the nasal skeleton and overlying skin. Blepharoplasty removes loose and protruding fat from the upper and lower eyelids. Therefore, when a client wants to address excess skin in the face and neck, rhytidectomy is the appropriate procedure.
Question 3
An LPN is reviewing medication lists for several clients recently admitted to the hospital. Which of the following scenarios would be least concerning?
A. A client taking allopurinol for gout states they have been taking black cohosh to help with post-menopausal symptoms.
B. A client has an order for warfarin and states they have been taking Ginkgo biloba to improve their memory.
C. A client taking Lipitor states they have been taking ginseng for an energy boost.
D. A client has a prescription for an SSRI and states they have been taking St. John's wort to also help with their depression.
Show answer and rationale
Correct answer: C — A client taking Lipitor states they have been taking ginseng for an energy boost.
The least concerning scenario is when a client taking Lipitor states they have been taking ginseng for an energy boost. While ginseng may cause an increased risk of bleeding, it should not interact with Lipitor. On the other hand, St. John's wort should not be taken with an SSRI as it may cause serotonin syndrome, posing a more serious concern. Black cohosh should not be taken with allopurinol as they can both cause hepatotoxicity, especially in combination. Ginkgo biloba should not be taken with warfarin as it causes an increased risk of bleeding, making it a more concerning scenario compared to the client taking Lipitor and ginseng.
Question 4
A nurse is preparing to administer medications to a client via a nasogastric (NG) tube. Before administering the medication, the nurse must first take which action?
A. Check the client's apical pulse
B. Check when the last feeding was given
C. Check the placement of the tube
D. Check when the last medications were given
Show answer and rationale
Correct answer: C — Check the placement of the tube
Before administering medications through an NG tube, the nurse must first check the placement of the tube to prevent aspiration. This is done by aspirating gastric contents and measuring the pH. Checking the client's apical pulse is unrelated to NG tube medication administration. Checking when the last feeding was given is important but not a priority before administering medications. Checking when the last medications were given is also not directly related to ensuring the safe administration of medications through an NG tube. Ensuring the correct placement of the tube is crucial to prevent complications such as pulmonary aspiration.
Question 5
Which client is at risk for hypomagnesemia?
A. Client with a history of heart disease
B. Client taking magnesium-based antacids
C. Client with a parathyroid disorder
D. Client admitted with alcohol abuse
Show answer and rationale
Correct answer: D — Client admitted with alcohol abuse
The correct answer is the client admitted with alcohol abuse. Alcoholics tend to have poor nutrition due to decreased food intake, which is a common source of magnesium. Additionally, alcohol suppresses the release of ADH, leading to diuresis and magnesium loss. Choice A is incorrect because a history of heart disease does not directly increase the risk of hypomagnesemia. Choice B is incorrect as taking magnesium-based antacids would not put the client at risk for hypomagnesemia; in fact, it would help prevent it. Choice C is also incorrect as a parathyroid disorder is not typically associated with an increased risk of hypomagnesemia.
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Question 6
A nurse working in a pediatric clinic observes bruises on the body of a four-year-old boy. The parents report the boy fell while riding his bike. The bruises are located on his posterior chest wall and gluteal region. What should the nurse do?
A. Suggest a script for counseling the family to the doctor on duty.
B. Recommend a warm bath for the boy to decrease healing time.
C. Notify the case manager in the clinic about possible child abuse concerns.
D. Recommend ROM exercises to the patient's spine to decrease healing time.
Correct answer:
In this scenario, the nurse is observing bruises on a child's body that are located in areas not commonly associated with accidental injuries. Given the concerning nature of the bruising pattern and the inconsistent history provided by the parents, the nurse should suspect possible child abuse and take appropriate action by notifying the case manager in the clinic. The safety and well-being of the child should always be the top priority. Counseling for the family, warm baths, or recommending range of motion (ROM) exercises are not appropriate actions in this situation and may not address the underlying issue of potential child abuse.
A health care provider asks the nurse caring for a client with a new colostomy to request the hospital's stoma nurse to visit the client and assist with colostomy care. The nurse initiates the consultation, understanding that the stoma nurse will be able to influence the client because of which type of power?
A. Expert power
B. Referent power
C. Coercive power
D. Reward power
Correct answer:
Power is the ability to influence others to achieve goals. Expert power results from knowledge and skills that one possesses that are needed by others. In this scenario, the stoma nurse's expertise in colostomy care gives them the ability to influence the client effectively. Reward power is based on the ability to grant rewards and favors, which is not applicable in this situation. Coercive power is based on fear and the ability to punish, which is not the case in seeking assistance for colostomy care. Referent power results from followers' desire to identify with a powerful person, which is not the primary influence in this context.
Ethics in nursing refers to the moral principles that govern a nurse's behavior and decision-making. It involves being able to differentiate right from wrong, making choices that are morally sound, and upholding integrity in patient care. While advocating for the client (choice A) is an important aspect of nursing care, it does not fully encompass the broad concept of ethics. Knowing your scope of practice (choice B) is essential for safe and competent care but is not a comprehensive definition of ethics. Being willing to report violations (choice D) is part of ethical practice, but it is not the core definition of ethics in nursing.
What could be a possible cause for the symptoms experienced by the client in Question 28?
A. iron deficiency
B. folate deficiency
C. peptic ulcer
D. iron overload
Correct answer:
Given the client's symptoms of fatigue, shortness of breath, and lightheadedness, along with her gender and fad dieting, the most likely cause is iron deficiency. Iron deficiency commonly presents with these symptoms due to decreased oxygen-carrying capacity in the blood. Folate deficiency would typically present with different symptoms such as mouth sores and changes in skin, not fitting the client's presentation. Peptic ulcer would manifest with abdominal pain, not primarily with the symptoms described. Iron overload would present with symptoms such as joint pain and fatigue, which are not consistent with the client's presentation.
The nurse is assisting the RN with discharge instructions for a client with an implantable defibrillator. What discharge instruction is essential?
A. "You can eat food prepared in a microwave."?
B. "You should avoid moving the shoulder on the side of the defibrillator site for 6 weeks."?
C. "You should use your cellphone on your right side."?
D. "You will be able to fly on a commercial airliner with the defibrillator in place."?
Correct answer:
The essential discharge instruction for a client with an implantable defibrillator is to use any battery-operated machinery on the opposite side, including cellphones. This is to prevent interference with the device. Additionally, the client should monitor their pulse rate and report any dizziness or fainting, which could indicate issues with the defibrillator. Choices A, B, and D are incorrect because clients with implantable defibrillators can eat food prepared in the microwave, move their shoulder on the affected side after the initial healing period, and are allowed to fly on commercial airliners with the defibrillator in place.
A nurse is reading the nurse practice act for the state in which she is employed. The nurse uses the information in this act for which purpose?
A. To understand hospital and long-term care facility policies
B. To know the scope of practice for nurses
C. To identify health care policies in her state
D. To be aware of the role of the licensed nurse
Correct answer:
The correct answer is 'To be aware of the role of the licensed nurse.' Nurse practice acts outline the scope of practice for nurses, defining what constitutes nursing practice and the role of licensed nurses. Choice A is incorrect because hospital and long-term care facility policies are institution-specific and not typically covered in the nurse practice act. Choice B is incorrect as the scope of practice for nurses is a part of the nurse practice act, but it's not the sole purpose for a nurse to refer to it. Choice C is incorrect as health care policies in a state are governed by other legislative acts, not the nurse practice act.
A nurse is covering a pediatric unit and is responsible for a 15-year-old male patient on the floor. The mother of the child states, "I think my son is sexually interested in girls."? The most appropriate course of action for the nurse is to respond by stating:
A. "I will talk to the doctor about it."?
B. "Has this been going on for a while?"?
C. "How do you know this?"?
D. "Teenagers often exhibit signs of sexual interest in females."?
Correct answer:
The most appropriate response for the nurse in this situation is to acknowledge that teenagers often exhibit signs of sexual interest in females. This response normalizes the mother's concern and provides reassurance that such behavior is typical during adolescence. Option A deflects the conversation to the doctor without addressing the mother's concern directly. Option B focuses on the duration rather than addressing the mother's statement. Option C may come off as defensive or dismissive, questioning the mother's observation. Therefore, the best response is to acknowledge the normalcy of teenage behavior regarding sexual interest.
A client visits the clinic after the death of a parent. Which statement made by the client's sister signifies abnormal grieving?
A. "My sister still has episodes of crying, and it's been 3 months since Daddy died."?
B. "Sally seems to have forgotten the bad things that Daddy did in his lifetime."?
C. "She really had a hard time after Daddy's funeral. She said that she had a sense of longing."?
D. "Sally has not been sad at all about Daddy's death. She acts like nothing has happened."?
Correct answer:
Abnormal grieving is often characterized by a lack of sadness or acknowledgment of the loss. In this scenario, the statement 'Sally has not been sad at all about Daddy's death. She acts like nothing has happened' indicates abnormal grieving as it suggests a lack of emotional response or denial of the death. On the other hand, choices A, B, and C all describe normal grieving reactions: crying episodes, selective memory of the deceased, and feelings of longing after the funeral. These responses are typical in the grieving process. Therefore, choice D is the correct answer, highlighting a potential abnormality in the grieving process.
A nurse is planning task assignments for the day. Which assignment is the least appropriate for the nursing assistant?
A. Assisting a client with dysphagia in eating
B. Ambulating a client with Parkinson's disease
C. Providing hygiene to a client with dementia
D. Assisting a client with an above-the-knee amputation in showering
Correct answer:
The least appropriate assignment for a nursing assistant would be assisting a client with dysphagia in eating. This task requires specialized skills and knowledge to prevent complications such as choking and aspiration. Ambulating a client with Parkinson's disease, providing hygiene to a client with dementia, and assisting a client with an above-the-knee amputation in showering are tasks that a nursing assistant can safely perform without significant risk of complications. Assisting a client with dysphagia in eating involves higher risks and requires specific training, making it the least appropriate choice for a nursing assistant.
A nurse is planning the assignments for the shift. Which task should the nurse assign to the nursing assistant?
A. Monitoring the vital signs for a client who needs a blood transfusion
B. Performing hygiene for a client with diarrhea on whom contact precautions have been imposed
C. Performing a dressing change on a client with a draining abdominal wound that requires frequent dressing changes
D. Ambulating a client with angina who needs to be ambulated for the first time since admission
Correct answer:
When assigning tasks, a nurse should consider the job description of the nursing assistant, their clinical competence, and state law. Monitoring vital signs for a client needing a blood transfusion, performing a dressing change on a client with a draining wound, and ambulating a client with angina are tasks that require a licensed nurse's skill. On the other hand, providing hygiene care for a client with diarrhea under contact precautions is a task suitable for a nursing assistant. Nursing assistants are trained to provide hygiene care effectively and manage clients under specific precautions, making this task appropriate for them.
NCLEX-PN clinical judgment practice questions, set 34 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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